‘Build it and they will come’ versus ‘the community readiness approach’. What leads to better implementation?

In 2003 Professor Sally Macintyre wrote an editorial for the BMJ which made a crucial point, it stated – “unfortunately, knowing the prevalence and causes of a health problem does not always tell us the most effective way to reduce it”. But not knowing the most effective way does not always stop implementers ‘doing something’. They are inclined to consider this is “better than doing nothing” (1).

We all know of some idea which was implemented with the best will in the world, but then ran into a quagmire of problems or just ran into a cul-de-sac. A good example is Swaach Bharat – A Clean India – the implementation of the sanitary movement launched with gusto by Prime Minister Narendera Modi in 2014. It is reported up to 48% of the Indian population do not have access to a sanitary toilet; in the villages, this figure jumps to 65% (2). These numbers are quite remarkable if we consider that India is the second most populated country in the world. Significant resources were pumped into building millions of toilets to curb the problem of open defecation and its associated disease burden. True to Modi’s words, the toilets were built and so the problems should have been flushed away.

But, things did not quite work out that way. Curiously, people would walk past the purpose-built toilets and continue with the customary way of going into the fields to relieve themselves, leaving policy makers and implementers puzzled. As is tradition, a government review was ordered to understand the reasons why people were shunning the toilets in favour of open fields. Researchers went from village to village to get some answers. After surveying 3235 people, the collated data reported an interesting range of replies. Most people said they found it “pleasurable, comfortable, or convenient to go outdoors”. Others said it “provides them an opportunity to take a morning walk to see their fields and take in the fresh air”. Still others regarded open defecation as “part of a wholesome, healthy virtuous life“ (2).

In this example, we can see why doing the wrong ‘something’ can be as bad, if not worse, than doing ‘nothing’. The wrong ‘something’ can lead to wasted resources which would be better used in other ways. This is where the Community Readiness Model (CRM) proves useful. It provides some approximation of the likelihood that a target community will tackle an identified issue, thus preventing a situation like the toilet example where implementation efforts and community willingness bypass each other. The CRM has its origins in the USA where it was first used to assess a community’s readiness to address alcohol and drug abuse. It has subsequently been applied to cover a diverse range of programmes including tackling domestic violence in Korea, childhood obesity in the UK, suicide in Canada and HIV/AIDs in Bangladesh.

The protagonists of the CRM describe how they applied interventions to tackle drug and alcohol abuse in two distinct communities, one with the CRM approach and one without (3). This made a big difference; the community which progressed along the CRM lines found the programme was well-received and highly effective, while the community where the intervention was introduced without any effort to gauge or improve community readiness experienced problems.

This early work was influential and a handbook on how to carry out a community readiness assessment followed (4). The authors stressed that communities experience many different stages of readiness and it is the job of the implementers to find compatibility between the implementation plans and the community’s willingness to take part. If the community is not aware about an issue, or displays resistance to an idea, or does not see it as a priority, then efforts need to be concentrated on improving these matters before rolling out the implementation. Using the sanitation example we discussed above, the mismatch between how the villagers and the authorities perceived the issue can be seen in the government-commissioned study, which concluded: “we find that many people have a revealed preference for open defecating such that merely providing latrine access without promoting latrine use is unlikely to importantly reduce open defecation (2).”

Community readiness is one of those ideas that may sound very obvious but this shouldn’t negate its worth. At its heart is an argument that any community is likely to be at one of nine possible stages for readiness to address any issue. These stages begin with one where the community has no awareness about the issue right through to nine where the community has high levels of ownership. The purpose is not only to gauge where a community is, using the scale, but to find ways to nudge it in the right direction towards stage 6 which they call initiation (see the diagram below for all stages).

Traditionally, programmes try to get a handle on community readiness through consultation exercises by asking the target community questions about acceptability, appropriateness and access. There is no denying that community consultation about these factors play an important role in health and social care planning, but we need to treat the findings from consultations as one set of indicators and not the full dashboard. How much we can infer from consultation exercises has puzzled Psephologists (people who try to make sense of public opinion polls) for decades, the recent election and referendum results in the USA and UK offer a case in point on how pollsters can get it wrong. At the health and social care level we face similar problems because what people ‘tell’ us and what they ‘do’ are not always the same thing. By way of example, research led by the University of Warwick asked parents who had children under the age of five about how likely they were to participate in parenting classes. The resulting data suggested 33% might participate and 10% were likely to participate. However, when take-up data was examined at the end of a pilot of free parenting classes, 6% of eligible parents had taken part. (5).

The behaviours and motivations of communities are not easy to predict and there are good reasons for this uncertainty including fluctuating levels of trust about services, community climate, politeness to the person asking (sometimes it’s easier to say things that researchers wish to hear) and because sometimes people do not know or recognise an issue that professionals may have spotted. Moreover, in some cases, it might be because the implementers and the community are on different wave-lengths and hold different opinions on how to define what a problem is. In Helen Pearson’s book on longitudinal birth cohort studies titled The Life Project (6), she describes when scientists took a detailed health assessment of the participants from the 1946 birth cohort study they were amazed to find how many people had one or more of the top 15 serious medical disorders which included, amongst other things, diabetes, heart disease and cancers. But amazingly, the cohort respondents either did not consider these to be a problem or were not aware they had them. Pearson describes it like this:

“(The researchers) found that a whopping 85% of the cohort had at least one of these conditions and that, on average, they had two disorders a-piece even though most of the people, when asked said they were in good health and a large number of conditions had not been diagnosed” (p302).

So, what does community readiness do differently to traditional forms of community consultation exercises? To help answer this question, it will be useful if we refer to an article by Erin Ross (7) in which she highlights the problem with the over-reliance on the wisdom of crowds. Put simply, if you ask a group of people to answer a question, the average answer should be close to correct. This idea, termed the wisdom of crowds, is that in large groups, errors of judgement should cancel each other out. We have seen a couple of examples above where this theory has struggled and so Ross advocates for a different approach whereby asking people with ‘specialised knowledge’ and using their understanding to predict how others may behave might lead to more helpful predictions. In making the case for this approach, Ross argues “in society, I think there is an assumption that the average opinion is generally right, and that’s been supported by past statistical arguments on crowd wisdom. But that’s not the way evidence works.” (7)

CRM follows this same logic. It begins with the task of interviewing key respondents who are considered to have specialist and esoteric knowledge about a community. These are people who work or volunteer with the community in question and who are likely to be able to answer questions about historical and planned efforts to address an issue. After interviewing key respondents about a range of topics including the community’s knowledge about the issue, leadership support and community climate, the transcripts that have been collected are then scored and a calculated which then enables researchers to place the community in a score from one to nine for community readiness.

We have applied this methodology to understand levels of community readiness amongst the Eastern European Roma community who have recently settled in the UK to tackle issues related to nutrition and obesity. Our findings have been shared with our funder, Better Start Bradford. Better Start Bradford is one of five Big Lottery funded programmes which have been tasked with improving the health and wellbeing of families with young children in parts of England where there are high levels of deprivation.

Our paper in the International Journal of Human Rights in Healthcare expands on our approach and discusses our qualitative and quantitative findings https://www.emeraldinsight.com/doi/full/10.1108/IJHRH-06-2018-0038

We encourage readers to consider the merits of using the CRM. Based on what we have discussed about the problems of inadequate implementation due to low levels of community readiness, we know it is far better to be roughly right than generally wrong.

1. Macintyre, S. (2003). “Evidence based policy making”, BMJ : British Medical Journal, Vol. 326, pp. 5–6.
2. Soutik Biswas BBC News (2014). Why India’s sanitation crisis needs more than toilets http://www.bbc.co.uk/news/world-asia-india-29502603
3. Edwards, R.W, Jumper-Therman,P, Plested, B.A et al (2000). Community readiness: research to practice. Journal of community psychology. Vol 28 no 3 pp291-307
4. Plested B.A, Edwards R.W & Thurman P.J (2006). Community readiness: a handbook for successful change. Tri-Ethnic Centre for Prevention Research.
5. Cullen. S. M., Cullen M.A. & Lindsay, G (2017). The CANparent trial – the delivery of universal parenting in England. British Educational Research Journal. Vol 43 no 4 pp759-780.
6. Pearson, H. (2016). The Life Project: The Extraordinary Story of Our Ordinary Lives.
7. Ross, E (2017). How to find the right answer when the wisdom of crowds fail. Nature: International weekly journal of science.

Authors Brief Biographies
Shahid Islam is a Research Fellow based in the Bradford Institute for Health Research and the University of Bradford with a special interest in community readiness and community engagement. Shahid is interested in exploring issues which focus on what works best for communities and why? His previous research projects have applied qualitative methods to explore issues related to service experience and outcomes for people who use mental health services. https://borninbradford.nhs.uk/about-us/meet-the-team/shahid-islam/

Neil Small is Professor of Health Research at the University of Bradford and a Fellow of the Academy of Social Sciences. Neil is a social scientist who has had an ongoing interest in health policy and health inequalities. For some years his research focused on chronic and life-threatening illnesses with a particular interest in end of life care. More recent concerns have been in health inequalities in babies and young children with a special emphasis on the impact of ethnicity. This interest is reflected in his position as Academic Lead for the birth cohort study Born in Bradford. https://www.brad.ac.uk/research/our-researchers/neil-small.php

Shahid Islam, Neil Small

Research Fellow, Professor of Health Research
Bradford Institute for Health Research and University of Bradford, University of Bradford